QUALITY IMPROVEMENT REPORT Effect of a flow chart on use of blood transfusions in primary total hip and knee replacement: prospective before and after study*

Problem: A suspected high proportion of unnecessary blood transfusions occur in patients undergoing total joint replacement. Design: Prospective before and after study evaluating the impact of a one page flow chart aimed at reducing the use of blood transfusions. Setting:Orthopaedic tertiary care centre in Winterthur, Switzerland. 208 patients underwent primary total joint replacement of hips or knees during the control period (October 1998 to September 1999) and 217 during the intervention period (October 1999 to September 2000). Key measures for improvement: Proportion of patients receiving allogeneic blood transfusions. Strategies for change: A simple one page flow chart, which summarised graphically the perioperative decision pathways for anaemic patients, was placed in all charts of patients undergoing total joint replacement and handed out to medical staff from 4 October 1999 onwards. The implementation of the flow chart focused on its endorsement by chief physicians and the development of a sense of ‘‘ownership’’ among physicians and nurses. Effects of change: The proportion of patients receiving allogeneic blood decreased from 35.0% to 19.8% (absolute difference 215.2%, 95% confidence interval 223.3 to 27.0%). The percentage of patients donating and receiving autologous blood also decreased. This led to overall savings of about £23 000 ($42 470; J34 441) (£103.50 per patient undergoing total joint replacement). Differences became more pronounced after adjustment for confounding factors. Lessons learnt: Allogeneic blood transfusions in primary hip and knee replacement surgery may be reduced cost effectively by implementing a one page flow chart. Five key elements may have contributed: simplicity; wide distribution; no requirement for major changes; endorsement by local opinion leaders; and development of a sense of ownership. These elements may be used in other contexts to achieve sustained change of clinical practice.